endocrine emergency

Endocrine Emergency

Chatlert Pongchaiyakul MD.

- Hypoglycemia

- Diabetic ketoacidosis

- Hyperosmolar non - ketotic coma

- Focal hyperglycemic seizure

- Thyroid Crisis

- Myxedema Coma

- Adrenal crisis

- Hypercalcemia

- Acute hypocalcemia

Hypoglycemia

ระดั�บ Plasma glucose ต่ำ��กว่� 50 mg/dl

“Whipple’s triad”

- low plasma glucose

- Neuroglycopenia

- Corrected by glucose

Classification

Fasting hypoglycemia

- underproduction

- overutilization

Post prandial hypoglycemia

Underproduction of glucose

Hormone deficiency

Enzyme defect

Substrate deficiency

Acquired liver disease

Drug : alcohol, propanolol,

salicylate,quinine etc.

Overutilization of glucose

Hyperinsulinism

– Insulinoma

– Exogenous insulin

– Sulfonylurea

Appropriate insulin

– Extrapancreatic tumor

– Carnitine deficiency

Treatment

• Oral intake

• Correct cause of hypoglycemia

• Monitor plasma glucose

Good conscious

Unconscious

50% glucose 50 ml IV. ต่ำมดั�ว่ย

10% Dextrose intravenous drip

125 - 250 ml/hr.

Glucagon 1 mg IM

Diabetic Emergency

DKA

HONC

Focal hyperglycemia

seizure

DKA

• Kussmaul’s breathing

• Polyuria, polydipsia, polyphagia

• Alteration of conscious

• Other : dehydration, nausea, abdominal

pain etc.

Diagnosis

Plasma glucose > 300-350 mg/dl

Wide anion gap acidosis

Serum Ketone + ve

not necessary

เกณฑ์�กรว่�นิ�จฉั�ยภว่ะDKA และHHNSDKA

Mild Moderate Severe HHNSPlasma glucose (mg/dl) >250 >250 >250 >600Arterial pH 7.25-7.30 7.00-7.24 <7.00 >7.30Serum bicarbonate (mEq/l) 15-18 10-15 <10 >15Urine ketones* Positive Positive Positive SmallSerum ketones* Positive Positive Positive SmallEffective serum osmolality (mOsm/kg)

Variable Variable Variable >320

Anion gap± >10 >12 >12 <12Alteration in sensorium or mental obtundation

Alert Atert/drowsy Stupor/coma Stupor/coma

*Nitroprusside reaction method; calculation: 2[measured Na (mEq/l)] + glucose (mg/dl)/18;±calculation (Na+) – (HCO3

- + CI- ) (mEq/I).

ที่��มา : ดั�ดัแปลงจากAmerican Diabetic Association 2001:S84.

HONC

Neurological Sign & Symptoms

Severe Dehydration

Evidence of infection

Diagnosis

- Plasma glucose > 600 mg/dl

- Effective Osmolarity > 320 mOsm/lit

- Serum Osmolarity > 340 mOsm/lit

- PH > 7.30

- HCO3 > 15 mEq/lit

- Prerenal azotemia

Treatment

Initial lab

CBC, UA, BS, BUN, Cr,

Electrolyte, ketone, ABG.

Calculated osmolarity

Septic work up

0.9% Na Cl 1000 - 1500 CC. ในิชั่��ว่โมงแรก 1000 CC. ในิชั่��ว่โมงที่ � 2 500 CC. ในิชั่��ว่โมงที่ � 3

250 CC. ในิชั่��ว่โมงที่ � 4 และต่ำ�อไป- ถ้� Na > 150 0.45% Na Cl

- ผู้&�ป'ว่ยสู&งอย) CVP

Fluid

Insulin

Short actig (IV / IM) - 10 u IV.

- 10 u IV drip / hr. ( ผู้สูมในิ Na Cl)

Monitor BS q 1 hr.

Electrolyte q 2-4 hr,

osmolarity, Anion gap

BS < 300 เปล �ยนิ 5% DW หร+อ5% DN/2 125-250 ml/hr.

Insulin 10-12 u Sc. q 4 hr.

หร+อ IV.drip low dose (2 u/hr)

NaHCO3 - pH < 6.9, 7.0

- Cardiovascular instability

: 100 mEq IV drip in 1 hr.

Potassium

If serum K 3 mEq ให� KCl 30 mEq/hr.

serum K 3-4 mEq ให� KCl 20 mEq/hr.

serum K 4-5 mEq ให� KCl 15 mEq/hr.

serum K 5-6 mEq ให� KCl 10 mEq/hr.

serum K 6 mEq ไม�ให� KCl

idividual adjustment with monitoring

THYROID STORM

Underlying hyperthyroidism

Without treatment, inadequate

treatment

Precipitating cause

Precipitating Cause

1. Inappropriate treatment

2. Surgery

3. Infection

4. Injury

5. Radioactive iodine

Principle

1. Supportive treatment

2. Specific treatment

3. Correct prcipitating

Cause

Specific treatment

Inhibit thyroid hormone synthesis

Inhibit thyroid hormone secretion

Inhibit thyroid hormone at

peripheral tissue

PTU

Inh. Synthesis, secretion, periphecal

conversion (T4 T3)

900 - 1200 mg/d x 1-2 d.

(4 x 4, 4 x 6, 2x12)

ฏdose 600 mg/dl

3 x 3 (450 mg/d) x 3 wk Definite

treatment

Iodine

Lugol’s solution (10 mg/drop)

10 drops q 8 hr.

SSKI (50 mg/drop)

4 drops q 8 hr.

Correct precipitating cause

Infection

Surgery

Advice antithyroid drug

Controversy

- blocker : 40 mg q 4 - 6 hr. - oral

(propanolol) 1 mg/min IV drip

Corticosteroid : Dexamethasone 2 mg IV

q 6 hr.

Practical point

1. ในิกรณ ไม�แนิ�ใจว่� Thyroid storm หร+อ severe hyperthyroidism ให�ร�กษแบบ

thyroid strom ไว่�ก�อนิ2. กรให� propanolol ย�ง Controversy

3. ถ้�จะให� corticosteroid ต่ำ�องแนิ�ใจว่�

สูมรถ้คว่บค)มกรต่ำ�ดัเชั่+.อไดั�ดั

4. ถ้�เก�ดั thyroid strom หล�งผู้�ต่ำ�ดัให� พิ�จรณ PTU / MMI rectal

suppository, contrast media injection

5. ต่ำ�องให� Lugol’s solution หร+อ SSKI

หล�งจกให� PTU ไปแล�ว่ 1 ชั่��ว่โมง6. ไม�ต่ำ�องรอผู้ล thyroid function test

Myxedema Coma

Hypothyroidisim

Thyroidectomy scar

History of I 131 treatment

Precipitating cause

1. Infection

2. Sedative drug

3. กรไดั�ร�บนิ�.เกล+อที่ �เป0นิ hypotonicity

4. Cold temperature

Symptoms & signs

Sign of hypothyroidism

Hypothermia

Bradycardia

Hypoventilation

Hyponatremia

Coma

Investigation

Routine lab

TFT, Electrolyte

EKG - low voltage

- Flattening or inverted

T-Waves

Principle

1. Supportive treatment

2. Specific treatment

3. Correct precipitating

Cause

Supportive treatment

Body temperature Correct hypoventilation Correct hyponatremia Coma care Hydrocortisone 300 mg

IV in 24 hr.

Specific treatment

Eltroxin

- 400 - 500 ug IV drip slow Day 1 or

1000 ug NG - tube

- Onset 6 hr.

- ฏdose 100 ug/d ในิว่�นิถ้�ดัไป

Correct precipitating cause

Evidence of infection and

treatment

Stop sedative drug

Advice Medication